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Department of Ophthalmology and Visual Sciences
Rick BlodiAugust 2019
Grand Rounds“Will I ever see my baby again?”
CCAcute, painless bilateral vision loss
HPI– 18 yo WF 2 weeks post-partum presented as
transfer to ULH from outside hospital– Woke up at 4:30 AM to breast feed with
normal vision. Went back to sleep– Woke up at 6:30 AM “completely blind”– “Will I ever see my baby again?”
Patient Presentation
Past Ocular Hx: contact lens wearerPast Medical Hx: 2 wks post-partum (uncomplicated, vaginal, epidural)Fam Hx: UnremarkableMeds: NoneAllergies: Nexium, omeprazoleSocial Hx: No smoking, drugs, or alcohol
ROS: +Nausea, vomiting
History (Hx)
OD OS
VA LP LP/HM?
Pupils 4→3mm No rAPD 4→3mm
IOP 16 mmHg 17 mmHg
EOM full full
CVF Unable Unable
External Exam
Anterior Segment ExamPLE OD OS
External/Lids WNL WNL
Conj/Sclera White and quiet White and quiet
Cornea Clear Clear
Ant Chamber Formed Formed
Iris Flat Flat
Lens Clear Clear
Posterior Segment ExamFundus OD OS
Optic NervePink and sharp, without pallor or edema
Pink and sharp, without pallor or edema
Macula WNL WNL
Vessels WNL WNL
Periphery WNL WNL
CT Head from outside hospital - Normal
MRI
• Several episodes of hypertension• Suffered seizure on the night of admission• Received Ativan, Mg, and Keppra• Was 20/20 OU next morning
Hospital Course
• 18 yo WF with acute, bilateral, painless vision loss with subsequent seizure. Benign eye exam. MRI notable for abnormal hyperintensity changes of bilateral occipital and posterior parietal as well as in the cortical area in right hemisphere
• Differential diagnosis:– Eclampsia– Posterior Reversible Encephalopathy Syndrome– Pituitary apoplexy– Central Serous Retinopathy– Venous Sinus Thrombosis– Posterior Circulation Stroke– Intracranial hemorrhage– Infective encephalitis– Autoimmune encephalitis– Toxic/metabolic encephalopathy
Assessment
• Fast onset• Most common symptoms:
– Headache– Altered mental status – Seizures– Visual disturbances
• Associated w HTN,transplantation, eclampsia, others
Posterior Reversible Encephalopathy Syndrome
• Underlying pathology is cerebral edema• Controversial – two theories
1. Severe HTN causes interruption of brain autoregulation2. Systemic inflammatory state causes endothelial
dysfunction
PRES Pathophysiology
• CT can be normal• MRI: T2-hyperintense vasogenic edema of
white matter in cerebral posterior regions• EEG to identify subclinical seizures• LP: r/o infection or subarachnoid hemorrhage
PRES Workup
Catheter Angiography
• Aggressive blood pressure management• Withdrawal of offending drug • Delivery in eclampsia• Antiepileptics for seizures• Ventilation for obtunded patients• Corticosteroids?• Prognosis: typical recovery within 8 days• Recurrence in 4% of pts
PRES Management
Rule out other causes
Venous Sinus Thrombosis
Herpes simplex encephalitis Basilar artery thrombosis
• Blurred vision• Homonymous hemianopsia • Cortical blindness• Visual hallucinations• Photopsias• Fundus and
pupils normal
PRES Visual disturbances
• Fast onset, headaches, seizures, vision changes
• Association with HTN, eclampsia, others• MRI shows bilateral, posterior edema• Treat underlying cause• Broad differential. Important to rule out other
causes• Important for ophthalmologists to be aware of!
Conclusions about PRES
• Hobson EV, Craven I, Blank SC. Posterior reversible encephalopathy syndrome: a truly treatable neurologic illness. Perit Dial Int. 2012;32(6):590–594. doi:10.3747/pdi.2012.00152
• Posterior reversible encephalopathy syndrome: clinical and radiological manifestations, pathophysiology, and outstanding questions. The Lancet- Neurology.
• Posterior Reversible Encephalopathy Syndrome, Parts 1 and 2: Controversies Surrounding Pathophysiology of Vasogenic Edema. J Neuro Radiology
• http://blog.clinicalmonster.com/2018/05/17/posterior-reversible-encephalopathy-syndrome/
• BCSC Neuro-ophthalmology• The posterior reversible encephalopathy syndrome: what’s
certain, what’s new? Practical Neurology. May 2011
References
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